Wednesday, November 25, 2015

The fact that primary care is undervalued by Medicare and other payers has been long-understood to be driving the precipitous decline in the numbers of new physicians choosing primary care internal medicine or family practice, and a growing exodus of established primary care physicians. Efforts to address this undervaluation have traditionally been to (1) bump up the payments (relative value units) for the office visit codes traditionally billed by primary care physicians, (2) explicitly fund, usually on a temporary basis, higher payments for primary care that do not require offsets from others, like was the case with the two-year Medicaid primary care pay parity program, which expired on January 1 of last year, and the five year 10% Medicare primary care bonus program, which is set to expire at the end of this year if Congress doesn’t continue it, (3) offer higher payments contingent on primary care physicians meeting performance measures (pay-for-performance), and/or (4) develop and promote alternative payments models, like Patient-Centered Medical Homes and Accountable Care Organizations, which offer higher payments in delivery models that require more accountability and risk for quality outcomes and savings.

Each of these approaches are important, and can potentially make a big difference, but each also has its limitations. Under Medicare’s “budget neutrality” rules, bumping up the RVUs for office visits results in across-the-board cuts in all RVUs, which intensifies resistance by other specialties. (Think of it like a pie: a bigger slice for primary care results in a smaller slice for everyone else) . And even the primary care services that are supposed to benefit from the bump end up having to absorb part of the budget-neutrality adjustment. And, because office visits are the most frequently billed services, even a small bump up can result in large across-the-board budget neutrality offsets. Programs to temporarily fund increased payments for primary care are all well and good, but because they are expensive, they also tend to be time-limited, depending on the willingness of Congress to keep open the funding spigot going past their expiration date. (Good luck with that!). Pay-for-performance programs can potentially increase payments to some primary care physicians but they are a hassle, usually include both penalties and rewards, require a lot of physicians to perform poorly in order for the better performing physicians to get more (another variation of budget neutrality), and physicians don’t have a lot of confidence in the measures being applied. New payment models may ultimately prove to be the best option to systematically improve payment for primary care, but there is an uncertain track record with them, and the investment in the practice that is required makes for an uncertain and uneasy cost-benefit for primary care physicians.

What if I told you there was another way, already available to primary care physicians, to potentially earn tens of thousands of dollars more from Medicare and other payers, while improving patient care? That is already built into Medicare’s budget neutrality adjustments, so there isn’t any resistance from other specialties? That doesn’t tie pay to performance measures? That isn’t time-limited and temporary, that doesn’t depend on Congress’s “generosity”? That is available within the traditional fee-for-service payment system, not linked to alternative payment models?

What if I told you that there is another way, one that takes a page out of the surgeons’ book? One of the way that surgical specialties have been able to earn higher payments is to constantly create new CPT codes and RVUs for their services, slicing and dicing what they do (pun intended) to create more billable opportunities. Why can’t primary care do the same, creating more codes and RVUs (and with them, more billable revenue opportunities), instead of being stuck with the same old 10 codes for office visits for new and established patients?

Well, this is exactly what has happened over the past few years in primary care. Largely because of ACP advocacy, Medicare has approved at least 7 new codes that create very substantial billable revenue opportunity for primary care physicians. Practices that bill for all of them can potentially increase their revenue by six figures, or more. (One company has developed a spreadsheet that physicians can use to estimate the potential revenue gains, as well as costs associates with the codes).

What are the new codes? Medicare’s wellness examination, which in 2016 will pay $172.69 for an initial visit, and $116.80 for a subsequent one. Transitions of care management, 14 day discharge, pays $164.81; 7 day discharge pays $232.52. Chronic care management, 20 minutes, pays $40.84. And, brand new, for the first time starting on January 1, Medicare will pay $85.99 for 30 minutes of advance care planning! (These payment amounts are before application of Medicare’s geographic adjustments, and apply to services provided in a non-facility setting).

ACP’s regulatory affairs department has prepared a nice spreadsheet that shows the available payments for these services in both the non-facility and facility settings.

Yet many primary care physicians are not routinely billing for these codes, leaving tens of thousands of dollars at the door. Many say that the documentation requirements are too much, or they might have to hire more staff, so it’s not worth the effort. There is no question that Medicare could make it easier and simpler for physicians to document these services, as ACP has recommended.

At the same time, though, I expect a cost-benefit analysis would show that many primary care physicians and their practices would come out way ahead if they began to bill for these codes, while improving patient care in the process—a real win-win.

So how about it, primary care doctors? Isn’t it time for you to consider taking advantage of the new codes and revenue opportunities available to you, even as ACP and others continue to advocate for more fundamental reforms to improve payment for primary care?

Thursday, November 12, 2015

We don’t really know, according to an ACP policy paper, written by me on behalf of our Medical Practice and Quality Committee and Board of Regents published in the Annals earlier this week. What we do know that the numbers of such practices are relatively low but there is growing interest in them, and judging from a live twitter session I just concluded, considerable passion from those who have embraced direct primary care.

Why did ACP decide to take on this issue? A few years ago, the ACP Board of Governors adopted a resolution from our Florida chapter asking us to look into developing policy on concierge practices. This resulted in a general statement of College policy encouraging physician choice of practice arrangements that best meet their patients’ needs in an ethical and accessible way. As time went on, though, it became apparent to us that a more detailed policy analysis and recommendations were needed, for several reasons.

It is now evident that increasing numbers of internists and other physicians are considering becoming part of a concierge, direct primary care, or some other practice arrangement that includes one or more of the following elements: (1) downsizing of patient panels (2) charging a retainer or concierge fee and/or (3) not participating in patients’ insurance. (Collectively, we define such practices in the new paper as direct patient contracting practices, or DPCPs.) The Affordable Care Act allows the insurance exchanges to offer direct primary care with a wrap-around high-deductible insurance policy. We also have had ACP members ask us whether the College has any policy or guidance on concierge or direct primary care practices. The growth of such practices can have a significant impact on quality, access and cost of care, as well as patient and physician satisfaction, yet little has been published in the available research literature on their impact.

For these reasons, our Medical Practice and Quality Committee accordingly decided that the College could make a positive contribution by doing an evidence-based analysis of the reasons why a growing number of physicians are interested in such models, what we know and don’t know about their impact on quality and access, what issues require further study, and ethical considerations that apply to physicians regardless of their practice mode. The members of our Medical Practice and Quality Committee who developed this paper included an internist in a direct primary care practice as well internists in more traditional independent practices. The Committee was unanimous in supporting the paper and its recommendations.

If you have not done so already, I encourage you to read the entire paper included as an appendix to the summary version published in the Annals of Internal Medicine. I think you will find that the paper is a balanced, objective, and evidence-based analysis of the implications of DPCPs as we intended. Several highlights:

•The paper clearly recognizes why many physicians are moving to DPCPs because of their frustrations with paperwork and insurance interactions, EHRs, and not being able to spend enough time with patients, and other external constraints on their ability to provide their patient with the best possible care. We call on policymakers to address such frustrations.
•We call on physicians in all types of practice to strive to provide care to all types of patients, including the poor and those on Medicaid, reflecting guidance from our Center on Ethics and Professionalism, Committee on Ethics and Professionalism, and ACP’s Ethics Manual on the obligation of all physicians to provide non-discriminatory care, regardless of their practice arrangement.
• We observe that there are examples in the literature of DPCPs that have structured their practices to ensure access to low-income patients, including Medicaid enrollees. Yet we also observe that there are concerns in the literature, supported by studies in our review of the evidence and input from our Committee on Ethics and Professionalism, which suggest that some practices that charge retainer fees and/or do not accept insurance could potentially create barriers to poorer patients who cannot afford to pay a retainer fee or pay out-of-pocket at the time the service is rendered.
•We address concerns about the potential for patient abandonment associated with downsizing of patient panels, which can create legal and ethical issues that physicians should be aware of.
•We provide practical suggestions for physicians who are in, or considering, a DPCP, to consider taking on their own to mitigate any adverse impact on poorer patients, such as waiving or lowering retainer fees, waiving requirements that payments be made at the time of service, and helping patients file claims.
•We call on all practice arrangements to be transparent with patients.
•We call for continued consideration of Patient-Centered Medical Homes
•We call for more research on the impact of DPCPs.

The paper neither endorses nor opposes direct primary care, concierge practices, or other DPCPs; rather, it just tries to provide a balanced assessment of their potential advantages and disadvantages and issues that merit further consideration by physicians, policymakers and researchers. Without more research, it would be premature for ACP to take a position on encouraging or discouraging them.

In summary, ACP affirmed our support for physician and patient choice of practices that are ethical and accessible and that best meet the needs of patients in a non-discriminatory way, whether in a more traditional independent practice, a large group practice, an academic practice, or a concierge practice, direct primary care, or other DPCP. And we call for more research on the impact of DPCPs on quality, cost and access to care.

Today’s question: What do you think of concierge and direct primary care practices, and ACP’s recommendations?